Artikel
Venous Coupler Size in Autologous Breast Reconstruction – Does it Matter?
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Veröffentlicht: | 10. September 2013 |
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Background: Autologous microvascular breast reconstruction has become an increasingly common reconstructive procedure. While the arterial anastomoses are traditionally being hand-sewn, the venous anastomoses are commonly completed with the aid of a coupler device. Whenever possible, the largest coupler size should be used which is determined, in cases of size miss-match, by the smaller of either the donor or recipient vein. While its efficacy has been shown using 3.0 mm size and greater couplers, little is known about the consequences of using coupler sizes less than or equal to 2.5 mm.
Methods: After obtaining an IRB waiver, a retrospective chart review of all patients undergoing autologous breast reconstruction was conducted at New York University Medical Center between November 2007 and November 2011. Flaps were divided into cohorts based on coupler size used: 2.0 mm, 2.5 mm, and 3.0 mm. Outcomes were measured by incidence of arterial insufficiency, venous insufficiency, hematoma, fat necrosis, partial flap loss, full flap loss, and need for future fat grafting.
Results: One-hundred ninety-seven patients underwent 392 flaps during the study period. Patients were similar in age, type of flap, smoking status, and radiation history. Coupler size less than or equal to 2.0 mm was found to be a significant risk factor for venous insufficiency (p=.038; risk reduction with coupler size greater than or equal to 2.5 mm 87%) as well as for development of fat necrosis (p=.041; 73% risk reduction) and future need for fat grafting (p=.050; 45% risk reduction). Interestingly, in multivariate analysis, BMI was found to be an independent risk factor for skin flap necrosis (p=.010) and full flap loss (p=.035).
Conclusions: Postoperative complications are significantly increased in patients requiring the use of 2.0 mm venous couplers and therefore it should be avoided whenever possible. Vessel modification including beveling or fish-mouthing, as well as more aggressive vessel exposure through rib harvest should be considered. Additionally, the use of thoracodorsal vessels or hand-sewn anastomosis should be considered in cases of internal mammary vein caliber of 2.0 mm or less.
Clinical Question: Therapeutic
Level of Evidence: Level III